Adrenal suppression ritonavir

Chen F, Kearney T, Robinson S, Daley-Yates PT, Waldron S, Churchill DR. Cushing s syndrome and severe adrenal suppression in patients treated with ritonavir and inhaled nasal fluticasone. Sex Transm Infect 1999 75(4) 274. 

Drug-drug iuteractions Ritonavir Inhaled fluticasone interacts with ritonavir, resulting in steroid accumulation, adrenal suppression, and even florid Cushing s syndrome. Fluticasone is metabolized by CYP3A4, which is inhibited by ritonavir. A systematic review of the hterature on adrenal suppression and Cushing s... 

Foisy MM, Yakiwchuk EMK, Chiu I, Singh AE. Adrenal suppression and Cushing s syndrome secondary to an interaction between ritonavir and fluticasone a review of the literature. HIV Med 2008 9(6) 389-96. 

Budesonide Inhibition of budesonide metabolism by ritonavir, through an inhibitory effect on CYP3A4, has been associated with adrenal suppression and Cushing s syndrome [128, 129 ]. 

Endocrine In a systematic review of 25 cases (15 adults and 10 children) of significant adrenal suppression secondary to an interaction between ritonavir and inhaled fluticasone, and three cases involving ritonavir and intranasal fluticasone, cases with other steroids were not reported [190 ]. The authors concluded that the combination of long-term fluticasone with ritonavir should be avoided and if ritonavir is required, another inhaled glucocorticoid, such as low-dose budesonide or beclo-methasone, can be used cautiously. When inhaled glucocorticoids are withdrawn, the patient should be closely monitored for adrenal insufficiency. 

Endocrine Iatrogenic hypercortisolism with or without adrenal insufficiency Locally administered glucocorticoids to patients on ritonavir can cause systemic toxicity. There has been a review of the literature [302 ] on this theme and several reports have documented hypercortisolism after topically applied, inhaled or injected steroids [303-311 ]. A randomised pharmacokinetic and pharmacodynamic study in healthy volunteers [312 receiving combination of beclomethasone with ritonavir (r) and DRV/r showed that DRV /r did not increase steroid exposure, whereas ritonavir alone did (2-fold increase). Adrenal suppression was not observed in any of the study groups. Caution when prescribing steroids to HIV patients on ritonavir is advised. 

Yoganathan K, David L, Williams C, Jones K. Cushing s syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection. Int J STD AIDS 2012 23(7) 520-1. 

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